HELP FOR PARENTS OF CHILDREN WITH ASPERGER'S & HIGH-FUNCTIONING AUTISM

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Aspergers Tantrums, Rage, and Meltdowns

Question

My eldest boy J___ who is now 5-years-old was diagnosed with Aspergers last July. We did 6 months of intense therapy with a child psychologist and a speech therapist before we moved over to Ghana. J___ has settled in well. He has adjusted to school very well and the teachers who are also expats from England are also dealing with him extremely well.

My current issue is his anger. At the moment if the situations are not done exactly his way he has a meltdown. Symptoms are: Extreme ear piercing screaming, intense crying, to falling down on the floor saying he is going to die. I have tried to tell him to breathe but his meltdown is so intense that his body just can't listen to words. I then have asked him to go to his room to calm down. He sometimes (very rarely) throws things across the room, but does not physically hurt anyone. As I have two younger boys (ages 1 and 3) I still need to be aware of their safety. I then managed to put J___ in his room with the help of a nanny. He throws all blankets off the bed (which doesn't bother me) and then hides under them. Today I waited 10 minutes then went upstairs to talk to him, but he then started again with the extreme crying and screaming at me. It took him over an hour to calm down fully. The situation arose as the nanny and I were helping him to make muffins and the nanny put a spoonful of the mixture into the muffin tin.

I am requesting your help on ways to calm him down in a manner that is acceptable. He is getting too old to be put in the "thinking corner/naughty corner" and I am a petite person so I'm not going to physically put him there. I am finding his resistance at the moment is a lot with me and his father.

I have structures in place by visual laminated pictures of how the morning is run and the structure before bed. This works fine, but like I said when things aren't done exactly his way, he can have an outburst in a flash. Please give me some strategies on how I can better manage these meltdowns.

FYI - he was diagnosed on the border on the CARS model. I have found a qualified speech therapist who is from England which we go to once a week (but as it is summer break we don't go back to August) to assist with his pragmatic language.

Answer

Problems related to stress and anxiety are common in kids with Aspergers (high-functioning autism). In fact, this combination has been shown to be one of the most frequently observed comorbid symptoms in these children. They are often triggered by or result directly from environmental stressors, such as:

a sense of loss of control

an inherent emotional vulnerability

difficulty in predicting outcomes

having to face challenging social situations with inadequate social awareness

misperception of social events

rigidity in moral judgment that results from a concrete sense of social justice violations.

social problem-solving skills

social understanding

The stress experienced by kids with Aspergers may manifest as withdrawal, reliance on obsessions related to circumscribed interests or unhelpful rumination of thoughts, inattention, and hyperactivity, although it may also trigger aggressive or oppositional defiant behavior, often captured by therapists as tantrums, rage, and “meltdowns”.

Educators, therapists, and moms/dads often report that kids with Aspergers exhibit a sudden onset of aggressive or oppositional behavior. This escalating sequence is similar to what has been described in kids with Aspergers, and seems to follow a three-stage cycle as described below. Although non-Aspergers kids may recognize and react to the potential for behavioral outbursts early in the cycle, many kids and teenagers with Aspergers often endure the entire cycle, unaware that they are under stress (i.e., kids with Aspergers do not perceive themselves as having problems of conduct, aggression, hyperactivity, withdrawal, etc.).

Because of the combination of innate stress and anxiety and the difficulty of kids with Aspergers to understand how they feel, it is important that those who work and live with them understand the cycle of tantrums, rage, and meltdowns, and the interventions that can be used to promote self-calming, self-management, and self-awareness as a means of preventing or decreasing the severity of behavior problems.

The Cycle of Meltdowns

Meltdowns typically occur in three stages that can be of variable length. These stages are (1) the “acting-in” stage, (2) the “acting-out” stage, and (3) the recuperation stage.

The “Acting-In” Stage

The “acting-in” stage is the initial stage of a tantrum, rage, or meltdown. During this stage, kids and teenagers with Aspergers exhibit specific behavior changes that may not seem to be related directly to a meltdown. The behaviors may seem minor. That is, kids with Aspergers may clear their throats, lower their voices, tense their muscles, tap their foot, grimace, or otherwise indicate general discontent. Furthermore, somatic complaints also may occur during the “acting-in” stage. Kids also may engage in behaviors that are more obvious, including emotionally or physically withdrawing, or verbally or physically affecting someone else. For example, the youngster may challenge the classroom structure or authority by attempting to engage in a power struggle.

During this stage, it is imperative that a mother/father or educator intervene without becoming part of a struggle. The following interventions can be effective in stopping the cycle of tantrums, rage, and meltdowns – and they are invaluable in that they can help the youngster regain control with minimal adult support:

1. Intervention #1 involves displaying a chart or visual schedule of expectations and events, which can provide security to kids and teenagers with Aspergers who typically need predictability. This technique also can be used as advance preparation for a change in routine. Informing kids of schedule changes can prevent anxiety and reduce the likelihood of tantrums, rage, and meltdowns (e.g., the youngster who is signaling frustration by tapping his foot may be directed to his schedule to make him aware that after he completes two more problems he gets to work on a topic of special interest with a peer). While running errands, moms and dads can use support from routine by alerting the youngster in the “acting-in” stage that their next stop will be at a store the youngster enjoys.

2. Intervention #2 involves helping the youngster to focus on something other than the task or activity that seems to be upsetting. One type of redirection that often works well when the source of the behavior is a lack of understanding is telling the youngster that he can “cartoon” the situation to figure out what to do. Sometimes cartooning can be postponed briefly. At other times, the youngster may need to cartoon immediately.

3. Intervention #3 involves making the Aspergers child’s school environment as stress-free as possible by providing him/her with a “home-base.”. A home-base is a place in the school where the child can “escape.” The home-base should be quiet with few visual or activity distractions, and activities should be selected carefully to ensure that they are calming rather than alerting. In school, resource rooms or counselors' offices can serve as a home-base. The structure of the room supersedes its location. At home, the home-base may be the youngster's room or an isolated area in the house. Regardless of its location, however, it is essential that the home-base is viewed as a positive environment. Home-base is not “timeout” or an escape from classroom tasks or chores. The youngster takes class work to home-base, and at home, chores are completed after a brief respite in the home-base. Home-base may be used at times other than during the “acting-in” stage (e.g., at the beginning of the day, a home base can serve to preview the day's schedule, introduce changes in the typical routine, and ensure that the youngster's materials are organized or prime for specific subjects). At other times, home-base can be used to help the youngster gain control after a meltdown.

4. Intervention #4 involves paying attention to cues from the Aspergers child. When the youngster with Aspergers begins to exhibit a precursor behavior (e.g., throat clearing, pacing), the educator uses a nonverbal signal to let the youngster know that she is aware of the situation (e.g., the educator can place herself in a position where eye contact with the youngster can be achieved, or an agreed-upon “secret” signal, such as tapping on a desk, may be used to alert the youngster that he is under stress). A “signal” may be followed by a stress relief strategy (e.g., squeezing a stress ball). In the home or community, moms and dads may develop a signal (i.e., a slight hand movement) that the mother/father uses with their youngster is in the “acting-in” stage.

5. Intervention #5 involves removing a youngster, in a non-punitive fashion, from the environment in which he is experiencing difficulty. At school, the youngster may be sent on an errand. At home, the youngster may be asked to retrieve an object for a mother/father. During this time the youngster has an opportunity to regain a sense of calm. When he returns, the problem has typically diminished in magnitude and the grown-up is on hand for support, if needed.

6. Intervention #6 is a strategy where the educator moves near the youngster who is engaged in the target behavior. Moms/dads and teachers move near the Aspergers youngster. Often something as simple as standing next to the youngster is calming. This can easily be accomplished without interrupting an ongoing activity (e.g., the educator who circulates through the classroom during a lesson).

7. Intervention #7 is a technique in which the mother/father or educator merely walks with the youngster without talking. Silence on the part of the grown-up is important, because a youngster with Aspergers in the “acting-in” stage will likely react emotionally to any adult statement, misinterpreting it or rephrasing it beyond recognition. On this walk the youngster can say whatever he wishes without fear of discipline or reprimand. In the meantime, the grown-up should be calm, show as little reaction as possible, and never be confrontational.

8. Intervention #8 is a technique that is effective when the youngster is in the midst of the “acting-in” stage because of a difficult task, and the mother/father or educator thinks that the youngster can complete the activity with support. The mother/father or educator offers a brief acknowledgement that supports the verbalizations of the youngster and helps him complete his task. For instance, when working on a math problem the youngster begins to say, “This is too hard.” Knowing the youngster can complete the problem, the educator refocuses the youngster's attention by saying, “Yes, the problem is difficult. Let's start with number one.” This brief direction and support may prevent the youngster from moving past the “acting-in” stage.

When selecting an intervention during the “acting-in” stage, it is important to know the youngster, as the wrong technique can escalate rather than deescalate a behavior problem. Further, although interventions at this stage do not require extensive time, it is advisable that grown-ups understand the events that precipitate the target behaviors so that they can (1) be ready to intervene early, or (2) teach kids and teenagers strategies to maintain behavior control during these times. Interventions at this stage are merely calming. They do not teach kids to recognize their own frustration or provide a means of handling it. Techniques to accomplish these goals are discussed later.

The “Acting-Out” Stage

If behavior is not diffused during the “acting-in” stage, the youngster or adolescent may move to the “acting-out” stage. At this point, the youngster is dis-inhibited and acts impulsively, emotionally, and sometimes explosively. These behaviors may be externalized (i.e., screaming, biting, hitting, kicking, destroying property, or self-injury) or internalized (i.e., withdrawal). Meltdowns are not purposeful, and once the “acting-out” stage begins, most often it must run its course.

During this stage, emphasis should be placed on youngster, peer, and adult safety, and protection of school, home, or personal property. The best way to cope with a tantrum, rage, or meltdown is to get the youngster to home base. As mentioned, this room is not viewed as a reward or disciplinary room, but is seen as a place where the youngster can regain self-control.

Of importance here is helping the individual with Aspergers regain control and preserve dignity. To that end, grown-ups should have developed plans for (1) obtaining assistance from educators, such as a crisis educator or principal, (2) removing other kids from the area, or (3) providing therapeutic restraint, if necessary.

The Recuperation Stage

Following a meltdown, the youngster with Aspergers has contrite feelings and often cannot fully remember what occurred during the “acting-out” stage. Some may become sullen, withdraw, or deny that inappropriate behavior occurred; others are so physically exhausted that they need to sleep.

It is imperative that interventions are implemented at a time when the youngster can accept them and in a manner the youngster can understand and accept. Otherwise, the intervention may simply resume the cycle in a more accelerated pattern, leading more quickly to the “acting-out” stage. During the recuperation stage, kids often are not ready to learn. Thus, it is important that grown-ups work with them to help them once again become a part of the routine. This is often best accomplished by directing the youth to a highly motivating task that can be easily accomplished, such as activity related to a special interest.

Preventing Tantrums, Rage, and Meltdowns

Kids and teenagers with Aspergers generally do not want to engage in meltdowns. Rather, the “acting-out” cycle is the only way they know of expressing stress, coping with problems, and a host of other emotions to which they see no other solution. Most want to learn methods to manage their behavior, including calming themselves in the face of problems and increasing self-awareness of their emotions. The best intervention for tantrums, rage, and meltdowns is prevention. Prevention occurs best as a multifaceted approach consisting of instruction in (1) strategies that increase social understanding and problem solving, (2) techniques that facilitate self-understanding, and (3) methods of self-calming.

Increasing Social Understanding and Problem Solving

Enhancement of social understanding includes providing direct assistance. Although instructional strategies are beneficial, it is almost impossible to teach all the social skills that are needed in day-to-day life. Instead, these skills often are taught in an interpretive manner after the youngster has engaged in an unsuccessful or otherwise problematic encounter. Interpretation skills are used in recognition that, no matter how well developed the skills of a person with Aspergers , situations will arise that he or she does not understand. As a result, someone in the person's environment must serve as a social management interpreter.

The following interpretative strategies can help turn seemingly random actions into meaningful interactions for kids with Aspergers:

1. Analyzing a social skills problem is a good interpretative strategy. Following a social error, the youngster who committed the error works with an adult to (1) identify the error, (2) determine who was harmed by the error, (3) decide how to correct the error, and (4) develop a plan to prevent the error from occurring again. A social skills analysis is not “punishment.” Rather, it is a supportive and constructive problem-solving strategy. The analyzing process is particularly effective in enabling the youngster to see the cause/effect relationship between her social behavior and the reactions of others in her environment. The success of the strategy lies in its structure of practice, immediate feedback, and positive reinforcement. Every grown-up with whom the youngster with Aspergers has regular contact, such as moms and dads, educators, and therapists, should know how to do social skills analysis fostering skill acquisition and generalization. Originally designed to be verbally based, the strategy has been modified to include a visual format to enhance child learning.

2. Visual symbols such as “cartooning” have been found to enhance the processing abilities of persons in the autism spectrum, to enhance their understanding of the environment, and to reduce tantrums, rage, and meltdowns. One type of visual support is cartooning. Used as a generic term, this technique has been implemented by speech and language pathologists for many years to enhance understanding in their clients. Cartoon figures play an integral role in several intervention techniques: pragmaticism, mind-reading, and comic strip conversations. Cartooning techniques, such as comic strip conversations, allow the youngster to analyze and understand the range of messages and meanings that are a natural part of conversation and play. Many kids with Aspergers are confused and upset by teasing or sarcasm. The speech and thought bubble as well as choice of colors can illustrate the hidden messages.

Conclusion—

Although many kids and teenagers with Aspergers exhibit anxiety that may lead to challenging behaviors, stress and subsequent behaviors should be viewed as an integral part of the disorder. As such, it is important to understand the cycle of behaviors to prevent seemingly minor events from escalating. Although understanding the cycle of tantrums, rage, and meltdowns is important, behavior changes will not occur unless the function of the behavior is understood and the youngster is provided instruction and support in using (1) strategies that increase social understanding and problem solving, (2) techniques that facilitate self-understanding, and (3) methods of self-calming.

Kids with Aspergers experiencing stress may react by having a tantrum, rage, or meltdown. Behaviors do not occur in isolation or randomly; they are associated most often with a reason or cause. The youngster who engages in an inappropriate behavior is attempting to communicate. Before selecting an intervention to be used during the “acting-out” cycle or to prevent the cycle from occurring, it is important to understand the function or role the target behavior plays.

More resources for parents of children and teens with Asperger's and High-Functioning Autism:

• Bieber, J. (1994). Learning disabilities and social skills with Richard LaVoie: Last one picked ... first one picked on. Washington, DC: Public Broadcasting Service.

• Bock, M.A. (2001). SODA strategy: Enhancing the social interaction skills of youngsters with Asperger syndrome. Intervention in School and Clinic, 36, 272-278.

• Bock, M.A. (2002, April, 30). The impact of social behavioral learning strategy training on the social interaction skills of eight students with Asperger syndrome. YAI National Institute for People with Disabilities 23rd International Conference on MR/DD, New York.

• Kuttler, S., Myles, B.S., & Carlson, J.K. (1998). The use of social stories to reduce precursors of tantrum behavior in a student with autism. Focus on Autism and Other Developmental Disabilities, 13,176-182.

• Rogers, M.F., & Myles, B.S. (2001). Using social stories and comic strip conversations to interpret social situations for an adolescent with Asperger Syndrome. Intervention in School and Clinic, 36, 310-313.

35 comments:

Anonymous
said...

An Aspie is like a juggler who can keep one ball in the air at a time, but struggles with more than one. Right now I am battling with four or five balls (problems) that just do not seem to get resolved and at times, like today, and my mind is on overload and cannot cope - it just goes blank, I forget things, lose things, which are uncharacteristic. Can you recommend anything to help me, please?

We have tried to ‘slow down’ and work around his temperament. We no longer ‘rush’ to do things and try to allow plenty of time because we found that by telling him we were ‘running late’ it only caused him to get more upset. We have tried to cut down/eliminate those items that we know send him on ‘sensory overload.’ We have altered his diet and we are still working at how to lessen/shorten the melt downs as well as what other things trigger them.

we tend to follow the same routine, or sequence of activities, we have to be careful about transitions, make sure that preferred foods are available, he needs very close following to see that homework and other non preferred activities are completed well so use picture schedules at times

My Aspie is a wonderful child but when he has his meltdowns it is getting scarier because he is 10 and the size of your average twelve-year-old. WHen he goes in to meltdown he throws things, hits the walls, kicks the doors, and won't stay in his room to calm down. We have no family or supprt so we are in this alone. The schools here won't help him and it got dangerous in school so I homeschool and we get social interaction through volunteering and chess club. He can't do team sports because he takes it personal when he gets bumped into. I am finding it more idfficult to keep my calm when he goes into melt down. WHat can I do to calm myself down. My degree is in Psychology and I am familiar with the cognitive-behavioral techniques but being human I find it difficult sometimes and fear that my emotions hinder my objectivity. What can I do? Can parents get anti-anxiety meds to take to stay calm during these episodes? I think sometimes we as parents need to be medicated as much as our Aspies so that we can do a better job of handling things. At least I think I do. Does anyone have any answers? I feel like a horrible persona to ask this but He can't get the best help when I am at the end of my rope. Thoughts?

I have an 18 year old who never finished year 9 at school. He gets physically violent when stressed i.e., if he has to go to the Dentist or some other situation and kicks and hits cupboards. He has Post Traumatic Stress Disorder which he used to be on tablets for but he didn't like getting fat so he stopped those. They really helped his Asperger's as well.

When I am sick and can't cook a meal he melts down and can't even think of cooking himself but is freaked out and will even wake me up to tell me I have to cook him tea. He gets verbally aggressive.

He is so full of anxiety it rules his life.

I am a single Mum, in my 50's and I have just been diagnosed with Asperger's as well. It is a relief because I always knew I was different.

To the mother who asked about meds for herself to be able to handle the meltdowns. I too struggle, just as you, and it got to the point where it was effecting my health, docs were worried about stroke or heart attack. So they did prescribe xanax for me, and I have to say at first I was against it..but when I felt I couldnt keep my cool, as my child started getting physical, it is at times like being in an abusive relationship..I started the med. I now function, and keep my calm. But I really want to learn how to help my child who is now bigger than I and only 7. I need help..what will I do when he turns 16..it does scare me..and to say that about my wonderful baby boy is the hardest thing to say..so you are not alone..I will keep you in my prayers.

My son also rages. My OTHER son has ADD (both dx'd with Asperger's). So I've got a little bit of experience in both. The raging was REALLY helped by Abilify but we were unable to stay on it due to rapid weight gain (7% of kids gain weight with it). The best replacement (and believe me we have tried most of them) is Intuniv, which is an extended release form of Guanfacine, a blood pressure lowering medicine that's been around for decades, better known as Tenex. Guanfacine simply lowers blood pressure, which has a result of lowering irritability and raging, since it takes more to get the child's blood boiling, as it were. Intuniv is being marketed for ADD right now (it did not help my ADD son, ONLY Focalin XR does that, a stimulant, it's a cleaner form of Ritalin).

I am surprised your child is being asked to take an ADD drug 3x/day. There are so many XR drugs out now that last 8-12 hours that a 4 hour pill is just silly. Admittedly, they are much cheaper, usually. I take the Focalin myself but in the 4 hour tab (it's 30 cents) vs. the Focalin XR that my son takes (8 hours; it costs $1). So i take 2-3 per day, but it lasts longer and I can adjust as needed. My son however needs it WITHOUT the SLUMP IN MEDICATION that can result from two 4 hour pills vs. one 8 hour pill. Something to look into, maybe...

My ADD son had trouble sleeping at one point. He's still not an easy sleeper but its better. He takes the 8 hour focalin, then he was also taking a 4 hour booster when he came home from school. If I gave it to him too late, the 4 hour pill (which actually lasts about 6 hrs in him) would keep him up at night. We no longer give him the booster, he's 14 and can handle the stress more at homework time. Plus he's at a therapeutic school with only 10 mins of homework per night. So maybe see if you can ditch the third dose? On a trial period to see if that's what is keeping him up.

Some kids with ADD do okay with Strattera which is NOT a stimulant but helps with the ADD. You could look into that as well.

At my son's school, when he would go into his rages in 3rd & 4th grades, they remove the class from the scene until the child can control himself enough, if he has gone to far to leave. They are pretty good about recognizing it, and he has a 1:1 aide who is with him all the time (after he threatened to kill the principal in front of 200 students in 3rd grade, we had an aide in 3 weeks. Amazing ...) She uses colored cards to signal things to him, since speaking can often be a trigger for rages. In 3rd grade they used to take him two floors down to the conference room or principal's office, but that kept backfiring as it was too far. Now (in 4th and 5th grades) they use the teacher planning room which is only 2 doors down from his classroom, and is often empty. When the class overwhelms him, he and his aide go there and work. This year, he went from being out of the class over 60% of the time, to missing only 35minutes in two weeks! after the Intuniv/Guanfacine XR kicked in (around week 4, at the 4mg dose; he weighs 170 and is 5'4; he's 11). Your school needs to get MUCH better at stopping the rage before it starts, otherwise it's a lost cause. The FBA (functional behavioral analysis) is a MUST. Request one in writing from your SPED dept.

My son has had an IEP for three years now. I'd be happy to send you a redacted copy of his goals and services pages to show you how they are handling his rage and other issues over time. I only have one year scanned into computer so it might take a couple of days.

So, my 9 year old son argues EVERYTHING! Tonight he was arguing....I pointed out that I am the adult, he is the child.....to which he argued. When I asked him who the adult was, he said we both were. When I asked him who the child was, he again said both. Prior to that he argued that there was no water on the floor. He dripped water while brushing his teeth....no big deal, but then he denied it was there. He was stepping in the puddle, swearing he could not feel it. I had him put his hand in it.....still couldn't feel it. Had him put his wet hand on his shirt......he couldn't see the wet mark on his shirt either. I finally threw some more water on the floor.......that he could finally see (I know, this was probably not the best way to get my point across).

The minute I get angry and raise my voice, things get worse....I know this. Problem is....I don't know how to deal with this without getting angry. I know I should probably let more go, but I worry I am letting him get away with things and he will never learn. With him, the more I give, the more he takes. I try to stay firm and consistent otherwise he walks all over me.

It is tiring and exhausting knowing that every request will be followed with resistence, arguing, or just plain ignoring. I watch people with their little 2-3 year olds and can't imagine what it must feel like to have a child listen so easily and well. He is my only child, so I really have never known what it is like to have a "normal" child who respects your authority. I sat in church yesterday watching families with 4-5 children do it with such ease, while my 9 year old stayed home because he was in a mood and had been feeling sick (although I don't know how bad he was really feeling at this point)....and I was too exhausted to deal with it (again.....letting him get his way cause he wears me down).

How do you do this day in and day out? I know I am often in a bad mood because of the constant negativity and defiance.....and I only have one child! Maybe there is a reason I was only blessed with 1??????

I have been on meds before, and that helps some, but it seems sooooooo wrong to have to take meds to deal with your child. How fair is that? Being a parent was suppose to be rewarding and full of joy...........

We see his neurologist on Wed and I think we are going to discuss meds. She wants to see him on a stimulant, but I am not so sure. Any suggestions on what might help some of these issues? What has been the biggest help for your children?

Gina:You did not say if your son is gifted or not. My son is gifted with adhd and Aspergers. He also used to argue to every request. This is a sign of very high intelligence. You may need to have his IQ tested. This might explain some of the arguing. I would not recommend a stimulant unless your son has ADHD. My son takes Intuniv 3mg and Lexapro 20 mg (For depression.) He also takes Imipramine 50 mg at night for bedwetting. He just turned 12.The intuniv really calmed him down and helped him control his anger.

Just a word about backing down because he wears you out: Don't do it. That only reinforces his behavior. It teaches him that if he argues, he gets what he wants.And, it makes it harder on you because he will keep exhibiting the unwanted behavior.

Please read the book, "Transforming the Difficult Child: The Nurtured Heart Approach." By Glasser. This is a positive, behavior modification approach that starts the kid off with no privileges, and they earn everything with a point system. This leaves you without arguing because THEY are in control of what they get to do. NOW, once you put it in place, then you can use punishment if you need to, which is a last resort. Your son will soon learn that with a point system in place, everything is in black and white. No gray equals no arguing. IF he behaves, he earns the point, when he gets X points, he gets to choose from X privileges. You no longer have to fight. He knows what to expect. The consequence for not doing anything is no points which equals no privileges.

Using this method, your child's incentives should change weekly. He should have something to work for each week. Even if it is only trip to the grocery store to pick out a dessert. Or a movie. Or a walk in the park with his dog.

Every kid wants something. You have to find out what he likes and put that as his reward. DO not give him anything or take him anywhere unless he EARNS it.This system works. I use it with my son and my daughter.

Also, with this type of child, you have to set a limit then walk away. Turn on the vacuumn cleaner or lock yourself in your room and turn the radio or TV up. DO NOT ARGUE WITH THESE KIDS. If you refuse to be an audience, he will quit talking.

Gina, your words resonate with me and break my heart. I hope you and I both find answers.

My little sweetie is my only child too, so all I can do is watch her agemates and wonder what it's like to have a child who is more responsive and obedient, who can make friends and enjoy herself, who I could take on outings without everything blowing up...this feeling of "this isn't what I signed up for" just makes me feel guilty, knowing that other families have more serious problems to deal with.

Anyway, blessings on you both. I wish you both peace, and joy in each other.

My child has aspergers, adhd. She is doing fairly well in school. We do disclipine, spanking if necessary. My child is very bright and knows who she can and cannot get her way with. If my child does she will run all over that person. I've had to fight the school system over this due to them giving the child 9 chances to do whatever she pleased in that school, hitting, biting kicking etc, etc, consistency is the key The school was told not to give aspegers/autism children consequences for their actions. I disagree with that. How is a child going to learn form right from wrong, if it's to that extent it is only going to become worse. Now the child is no longer hitting, biting, kicking in school.

I have a younger brother with Asperger's and always found the post-meltdown self-criticism so heartbreaking for him. While the rage was sometimes uncontrollable, he retained an awareness of the damage he had done and was sensitive to the remaining stress level after he had calmed down. Convincing him that everything was OK so that we could talk through what had happened seemed to take much longer as a result.

Geneva could I please talk to you? You offered a copy of goals for the iep. My 9 yr old as pie is struggling with school and doesn't want to go. He tantrums badly at home and it gets ugly. I think it is related to school stress. I think we need a fba. We had an independent eval but a behavior therapist never came in to observe him. He is on overload. He gets OT 30 min but is is not helping sensory at all. Thank you! Michele Michele _223@hotmail.comTonight he threw a rage so bad at tutor. He threw over chairs, cussed at her locked himself in car, started it up, destroyed it inside and blared the horn. Help!

My step-son is about to turn 12. He has been diagnosed with Asperger's Syndrome. He currently lives with his mother and step-father and half sister. My husband and I live with our son and my two daughters. My step-son has had numerous meltdowns off and on for most of his life. He seems to pick one thing out of his life and fixate on it until he is so afraid of it that he has a meltdown. These fixation normally last for six months or more until all of a sudden, he is no longer afraid of it but finds a new thing to fear. Currently, he is fixated on being scared of coming to visit his dad and is constantly making up excuses not to visit. We have tried to explain to him that there is nothing to be afraid of. We love him very much. He told me that he is afraid that his dad will yell at him or get on to him. Now, I have been with my husband for 7 years and I have seen that the only thing he gets in trouble for is the normal everyday stuff that children get into trouble about. We treat him as we do the other three. From everything that I have read I feel that he should face his fears in order to get past it. But, me being just a step-mom, anything I say doesn't matter or is taken the wrong way. We are getting no help from his mother or any of the other family members who all feel that if he doesn't want to visit, then it must be something that we have done to cause. But, last year when he freaked out about going to school every morning, did they just let him quit? NO! I know this is a tough one. Any opinions would be greatly appreciated. This is not only affecting my husband emotionally, but also my son. He misses him terribly too!

What you are dealing with here is anxiety. Although little is known about what anxiety symptoms look like in kids with Aspergers, the following symptoms, which overlap with Anxiety Disorders, indicate anxiety:

• Avoidance of new situations• Irritability• Somatic complaints• Withdrawal from social situations

Another set of anxiety symptoms may be seen and may be unique to kids with Aspergers:

Cognitive behavioral therapy, a time-limited approach designed to change thoughts, emotions, and behaviors, has been shown to be successful in treating Anxiety Disorders in kids.

For kids with both anxiety symptoms and Aspergers, an innovative group therapy program using cognitive behavioral therapy has been developed. The program includes specific modifications for working with kids with Aspergers and Anxiety Disorder and consists of both a child component and a parent component.

Modifications designed to address the cognitive, social, and emotional difficulties include:

1. More education on emotions—Activities such as feeling dictionaries (i.e., a list of different words for anxiety) and emotional charades (i.e., guessing people's emotions depending on faces) are helpful in developing emotional self-awareness.

2. Greater parent involvement—To build on the attachment between youngster and caregiver, it is important to have moms and dads learn the techniques and coach kids to use them at home.

3. Games and fun physical activities are important to include in group therapy to promote social interactions.

4. Combining visual and verbal materials—Use of worksheets, written schedules of therapy activities, and drawings can be added to increase structure in therapy sessions.

5. Behavioral management—Addition of a reward and consequence system maintains structure and prevents anger outbursts.

6. "Individualizing" anxiety symptoms—Kids should be helped by the therapist to identify what their own anxiety symptoms look like as anxiety symptoms may present differently.

There is some early evidence to suggest that cognitive behavioral group therapy with specific modifications can be successful in treating anxiety symptoms in kids with Aspergers. In a study involving kids with both disorders, most benefited from their participation in the group therapy program and showed fewer anxiety symptoms after 12-weeks of consistent attendance. Future research is being done to get stronger evidence for the effectiveness of the group therapy program.

I have been trying for years to understand and get help for my daughter, who will be 11 years old in December.

She has had a variety of problems starting at about age 1, including sensory issues, pulling almost all of the hair out of her head at the age of 5, constant meltdowns, rigid thought patterns.....I could go on and on.

We have had her to her pediatrician, who told me years ago when I was begging for help that it was her personality, and I needed to learn to "deal with it."

We have also seen therapists, who did little to help with the problems we were having.

Finally, after her behaviors have escalated with the start of the school year, I pursued help and got started with a new therapist. I took the time to sit down and write out two pages of background information for the therapist, including anything I thought would possibly be relevant.

After going over everything in detail and asking a lot of questions, the therapist asked if anyone had ever mentioned Asperger's to me. Honestly, the thought had crossed my mind, but I wasn't sure.

The more I read about Asperger's, the more I see that the behavior problems we have been having all these years seem to fit and now make sense.

I'm relieved to finally have someone take the time to understand my daughter and help us get the help she needs and help us to understand her more. My fear has always been that she will feel lost and misunderstood. I hope that now we will be able to make her life better.

Thanks so much for the information on this page, it is going to be invaluable as we get started on helping her to deal with her meltdowns.

My 12 year old HF Aspergers son refused to go to Alternative school today after a meltdown on Friday and being put in a time out room for most of the day. He has an IEP and recently got put into the public alternative school because of several meltdowns at his main school resulting in him hurting another kid when he threw a chair. He did not mean to hurt anyone and was not aiming to hit her she was just in the line of fire. The only school he wants to go to is is main school and he has only made it four days in the alternative school. Now he refuses to go and according to the school system he has to complete a 8-10 week program to be able to go back to his main school. He knows what is expected but is refusing all options. He thinks they need to just let him go back and give him another chance, I do not think that will happen and now I do not know what to do.. I offered him home school but he is refusing that option as well. Any help with this situation would be appreciated.

My 10 year old son seemed to be getting better about this a few months ago when we started meds, but things have been going down hill again. I am totally exhausted after this weekend. Right now his obsession is his Dad and his Dad's Mustang. This would be so bad, but my family (and probably my boyfriend) are getting really annoyed with it. My ex isn't exactly well liked around here, so that doesn't help......

Anyway, here is how my day went:

Took him shopping at Dick's sporting goods. After I got him through the parking lot hearing about how his Dad's Mustang compares to every vehicle in the parking lot, he decides he hates shopping at this store. As we are walking in, he is going on and on about how much he hates the store and why would anyone name a store after a dirty word. After multiple times of telling him to stop and that he is being inappropriate, he continues on with the dirty word talk right past the greater!

On to the back of the store where he decides he needs a lock for his roller skates. I tell him to ask for it for Christmas, but they just can't wait. He has had the skates for months, but they could be stolen at any moment now! He proceeds to follow me around the store pleading his case endlessly. He finally sits down in the shoe area with my boyfriend and his son. At this point he is being down right mean to me, so I walk away and leave him with the boyfriend. He continues to tell them how mean I am, how I don't care about him, and so on. He just can't figure out why I wouldn't let him spend $8 of his money when that would be so much cheaper than losing $200 of his Dad's money!

The fun continues at church where we sit behind a couple with a small infant. The baby is taken by my son, but he refuses to smile......smiling in front of people embarrasses him (and makes for fun pictures with him!). At some point he does decide to make faces at the baby, some not so appropriate. Luckily, he decided to ask me before making the "Chinese" face at the baby.....they were likely Chinese!!!

Then we have a melt down before bed because he decided he needs to make a birthday card for his dad, RIGHT NOW......his birthday is not until next Wednesday!

He told everyone at his birthday party yesterday that the cake was good because it was his recipe (he picked out the flavors). When someone suggested I get credit for baking it, he continued to argue that it was his recipe. Today, when my boyfriend told him the cake was so good because he did a good job at coming up with the recipe......he argued that I was the one that bake it!

My almost 3 year old niece was here yesterday and I realized that she is WAY easier than my 10 year old. She needs less correcting and usually listens when I tell her something. My son needs to be told numerous times before I usually have to go make him do whatever I am requesting. How does this not totally depress a person????? Does this ever get better? Do certain meds really make a difference?

I want to enjoy my son, but I feel like these behaviors make is hard at times. If it is hard for me, I imagine it is almost impossible for anyone else. My boyfriend, my family, teachers, and especially his peers. Any suggestions? I want him to be likeable, but he can make that so hard......and that kills me to even admit!

Hi, I'm new to the group. My son just turned 4 and he's recently been downgraded from Moderate Autism to Aspergers with SPD. We've done 18 months worth of OT, ABA, etc. and it's worth the effort. I'm looking for others who face a lot of the daily challenges. My husband travels a lot - so I'm left with a lot of the behaviors, tantrums, daily schedules, etc. It's lonely out here handling most of this on my own. Anyone else out there in the same situation?

Hi, My daughter started having meltdowns in 6th grade and she would get sick too , it took some time for her to pass but my experience just got worse she is 14 now and had to be put on medication to control the meltdowns and obsessions.

My Aspie gets sick over basically being anxious about things. She got sick the other night because she was nervous about the 6th grade dance, a math test, and we believe her pet rabbit ( one if her obsessions is animals) is dying. She threw up once and then was fine.

Thanks for the comments. I have a beautiful daughter with anxiety and aspergers also, the tantrums are exhausting for her and me. I am a single mom with not a lot of support. I always end up in tears with her by the end of the meltdown. The hard part is the tantrums are usually over small stuff and switches throughout the meltdown so I can't figure it out. I know I am to stay calm but after time I lose my patience! I can't seem to get control. Her doctor does not want to medicate again because her recent meds gave her tics! Hiring in home aba but of course everything that is there to help our kids is expensive and often not covered under insurance. Good luck to you all and God Bless!

Wow - thanks to everyone for your comments and thoughts. I have a 9y.o. son with Asperger's + co-morbities of OCD & ODD. We are in a particularly harrowing stage of constant arguments and major meltdowns...and it is SO scary and exhausting for him, and the rest of the family. He is on medication but we are at our wit's end at the moment and are struggling to cope - we just want our son to be happy and it is heart breaking to see him so distressed, so often.

Thanks for the suggestion of the Glasser book Jenn (June 30, 2011). I had heard this was good and will endeavour to get this now.

my 9 year old was just recently diagnosed,though we have suspected it for years.My biggest fear is her "meltdowns"often driving in the car she will attack her 7 year old sister unprovoked or throw things at me while i am driving.I find myself not bringing her to certain places because i fear she will do this in front of others and they wont understand.I have NO idea how to begin to handle these outbursts or stop them from happening.we are late to school EVERY day and the school hasnt exactly been understanding.I physically have to carry her against her will kicing and screaming,often dressing her in the car at school.Can someone PLEASE help me and tell me where to start??I am SOOOO overwhelmed!!Like · · 5 hours ago

I found your video today on the differences between Asperger meltdowns and regular tantrums -- well, interesting enough -- and of course you're peddling your book on dealing with Asperger kids to their parents. Alas, I'm nearly 54, and still having meltdowns -- though at least I can tell when they're coming (only took me 3o-35 years to figure that out,)-- your bit about the silent trance stage was illuminating, in that that's exactly what happens -- I become near catatonically still, and my mind goes sort of blank as some rush of energy whooshes in and all hell breaks loose -- but at least since I now can sense when it's about to happen I try to get as far away from everyone as quickly as possible -- though of course this hardly endears me to anyone I know, and most just say something like, "Oh, get over it," or some such blather that makes no sense to me at all -- frankly, it's not very helpful considering it's like an out-of-body experience. Well, enough of that ...

the question I have, which I keep trying to find answers to -- what do I do about this? What advice is there for adults? And you know, when I was a kid no one knew about this -- my parents just sent me away to summer camp for three months to give them a break I guess -- but really, it's getting ridiculous -- I can't explain to anyone what is happening, or why it happened -- I can't figure out what triggers it - I can't figure out a way to stop it - they look at me like I'm insane, and so what advice is there for me?

My son who is now 14 is an Aspie also, I am hearing allot of the negative vs positives. One thing I am trying to focus on is his ability to focus on one subject that he enjoys. There focus ability is amazing compared to most. They are like little genius'sIf we could focus on quality education funding for these children, and even the adults we could not lose. The social problems will always be there, we are constantly involving him in our family conversations at dinner. Trying to make sure he focuses on what we are talking about otherwise he will start a whole new subject. But when he is interested in something like guitar hero, he would play till he was the best and beat everyone online. When they are out of control, the last thing you want to do is scream at them, only makes it worse. My son will usually lock himself in the bathroom, which is fine cause hes not making fists at me, which he does and don't realize it as a threat. There are good qualities , better then a normal social person has that can be so helpful in today's world. Lets find our new astronomers, scientists, meteorologist, there hidden in your child try to find the good stuff.

Don't assume that the person labeled with Asperger's doesn't understand. It may be that his understanding of the other parties' subconscious motivation or of the factors as a whole is deeper than your own. For example, one might see a big smile and think "unusually happy" while having a sense of unease. An Aspie would identify the unease as being a contradiction and deduce that this was a fake smile, and go on to conclude something different about the person faking a smile. This might cause the Aspie to be on the losing end of discussions of "whose error", since many people would conclude ad populum that he is wrong.

This is a specific example of my rule #1 for dealing with Aspies: Don't assume misunderstanding when superior understanding would suffice to explain the situation.

We have a child who is nine years old, diagnosed with Asperger's Syndrome. We've spent literally thousands of dollars trying to help her - speech therapy, behavioral therapy, occupational therapy, Learning RX, vitamins and minerals, biomolecular therapies involving bloodwork and stool samples, herbs, amino acids, etc... basically everything. At this point, I am ready to throw in the towel, divorce my husband who thinks she has nothing wrong with her, and claim sole custody of my younger child (who does not have aspergers) in order to keep her away from the destructive and chaotic behaviors of my older child. I have fought with school teachers, principals, and school pyschologists to better help them understand who and what my daughter is. We can no longer afford any more "novel" treatments to this disorder, and I am now convinced that she will simply always be this way, regardless. This is a disorder that is extremely damaging in every regard, and with no "cure" in sight, it's hopeless to try anymore. She will either end up in a hospital or in jail, and there is nothing more I can do to prevent this.

I have a 3 yr old who is on the edge of Asperger's dx. We have struggled horribly with his tantrums, and extreme meltdowns that sometimes last all day long. I am just starting to really research Asperger's as this type of DX had never really even crossed my mind. He was born 12 wks premature, so I always just thought he was behind developmentally. However, he is such a bright child, and for his age is very intellegent. He does very well on his, own, or with just 1 or 2 other kids, but the minute a 3rd child, or group comes into the picture, he seems to completely get overstimulated or overwhelmed and loses control of himself. Even during daily, routine activities that he should be used to, the transition from one thing to the next can sometimes just be so overwhelming that he cannot cope. It is such a scary sitation to be in knowig he is only 3 and his tantrums/ meltdowns have gotten this severe already. I am looking for any tips, information, anything that can help us to help him and make his life a little easier, and help him manage a little better....... please...... Thank you

I'm grandmother to a child diagnosed with Autism. My daughter is 6 months pregnant, 35 years of age, and only getting about 4 hours of sleep each night. She is completely exhausted. Her son, William, 2yrs old February past, wakes up each night many times screaming, having what she says is "night terrors" it seems. Her husband has to wear earplugs just to get enough sleep to go to work everday while she contends with her son, though he has to help sometimes as well. William is very unpredictable and can begin screaming at any moment anywhere. Your video shows exactly what she described to me in the grocery stores, people staring, giving her looks like why can't you control your child. She remembers being one of those people before having children - now she understands. He is only quiet when she shoves the ipad in front of him, again with looks from other parents in the store. He is very intelligent, knows all the ABCs inside out, counts to 30, knows months of the year, days of the week and writing a few words and reading them, like mama, papa, thank you, etc (due to the ipad mainly and perhaps his autistic side showing through). He sees a doctor who has two autistic children of his own, but who hasn't offered them much in the way of advice at all. She feels very alone, but for me to talk to, so we are both floundering big time.

He is such a beautiful and loving child otherwise but she and her husband don't know how to handle his outbursts. She doesn't want to leave the house anymore. I'm very worried and can't provide relief for them as I live 4000 miles away. Please help! I will encourage her to contact you as it sounds like you have many happy parents who have tapped into your book and advice. Oh, I should mention also that he has a syndrome called Demorsier's Syndrome as well which caused him to be only partially sighted (about 50-60% vision). He seems to have learned ways to compensate for that though and other than needing to be close to objects to see them and not being able to determine depth and spacial areas, he seems to be fine otherwise.

I am in the final stages of completing your 4 week my aspergers teen course. I am so happy that my son's meltdowns are occuring less frequently and less intensely. Thank you for giving me the information needed to become an assertive parent.

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My 9 year old son is an Aspie with OCD. he is the size of a L man & shoe size 43 (9 UK)whe he meltsdown hes a handful and sometimes im physically afraid. Only recently diagnosed, hes only displayed meltdowns for 18 months. Ive learnt a lot in this short time but still misinterpret daily. I no longer challenge/ argue/ confront/ discipline him, its too tiring for me and is a trigger for him. I spend a lot of time discussing things with him and have found putting large squishy scatter cushiones in his bedroom (safe haven) and investing in a large pink Gym ball has helped massively. When he feels 'off' he will shout me and we throw the ball to 1 another and chat about anything until hes calmed down. I get up 2-3 times a night with him as he wets bed and as he has OCD it actually terrifies him. Only last night, we went to his favourite carvery restaurant, he needed a wee and I could see him building up. My husband (his Dad) accompanied him but the meltdown had already started. We didn't finish our drinks or order food as he started bending cutlery and screaming swear words, the whole place fell silent apart from 1 elderly lady who verbally expressed disgust. I apologised to the sniggerers and haters and we left.1 younger lady put her hand on my arm and said 'don't worry, safe journey home'. We got home, he showered and as he tried to retreat to his room, I fetched out fresh blankets, sweets and coaxed him into sitting on the sofa with me & Dad. We watched a movie, chatted, laughed and all went to bed happy. Ive accepted IT IS WHAT IT IS, getting angry, getting upset, fighting against it just accelerates and enhances it. Educate oneself, try different things until you find something that works for you. Each case is individual and is your life, your story. I join groups, chat regular and it helps. I'm tired, sick of endless washing, I have 3 older children and work full time too! I live with the positive thought that it will get better and he will eventually be able to manage/ cope as he gets older but I know its a lifelong condition and he will always need support. We have lots of laughs and his intelligence provides us with such entertainment and knowledge that he amazes me daily. Im at the beginning of this journey with an Aspie/OCD kid and im exhausted, anxious, cry a lot and feel overwhelmed BUT hes my son and I cannot change anything so I ride the wave and take each day at a time. I DONT RUSH, try to be well organised as rushing/ shouting is a trigger. I WALK WITH HIM whenever possible as I find the car is a trigger. I DRAW and SIGN to him. If I want to speak to him I SAY HIS NAME, wait for him to engage and then we talk. I DONT SHOUT OR SMACK, I walk away, sit quietly, have 5 minutes, write it down then go back and try again. Nobodys perfect, meltdowns are scary, life sometimes feels bleak but roll with it. x

My son is HF Austistic and severe anxiety and mood disorder...Hes 11 yrs old and we just now this week started homeschool cause the schools could not keep cause they said they just dont have the time to spend on him allday an he is a threat to teachers and himself..I thought this homeschool would help but he fights me on it once he gets to a certain point in his studies he just shuts down and wont do it..His anger and rage has turned violent and he constantly is hurting me,,He has broke to many things to count and left to many bruises through the past to count..He sees a psychiatrist but alot of meds dont work for him..We are thinking its his body isnt metabolizing the meds correctly..I need help and dont know what else to do..He cant go to school due to stressors of school and this homeschool looks like it may not work out..Ive been stressed and overwhelmed all week and so has he..Any advice would be appreciated

My son is two years old.- he can be playing fine one minute then just starts screaming. I have been unable to identify a trigger and there aren't any act in signals. It can take up to an hour to co.pletely calm him. This behaviour started a week ago and initially I believe he was suffering a migraine as he was even more sensitive to light than he usually is. He screams and genuinely Cry's like he is in pain and scared. He Cry's nigh-nights and I have to give him his blanket and dummy which are reserved for bed times. He has a strict meal routine and is a very happy child although he has delayed speech and displays early aapie traits. Fascination in numbers. I know that upsetting the routine can cause a tantrum but these freak outs with no apparent reason are ... Well freaking me out. Any tips for identifying a trigger or act in signal would be greatly appreciated.

My child has been rejected by his peers, ridiculed and bullied !!!

Social rejection has devastating effects in many areas of functioning. Because the Aspergers child tends to internalize how others treat him, rejection damages self-esteem and often causes anxiety and depression. As the child feels worse about himself and becomes more anxious and depressed – he performs worse, socially and intellectually.

How to Prevent Meltdowns in Aspergers Children

Meltdowns are not a pretty sight. They are somewhat like overblown temper tantrums, but unlike tantrums, meltdowns can last anywhere from ten minutes to over an hour. When it starts, the Asperger's child is totally out-of-control. When it ends, both you and the Asperger’s child are totally exhausted. But... don’t breathe a sigh of relief yet. At the least provocation, for the remainder of that day -- and sometimes into the next - the meltdown can return in full force.

Parenting Defiant Aspergers Teens

Although Aspergers is at the milder end of the autism spectrum, the challenges parents face when disciplining a teenager with Aspergers are more difficult than they would be with an average teen. Complicated by defiant behavior, the Aspergers teen is at risk for even greater difficulties on multiple levels – unless the parents’ disciplinary techniques are tailored to their child's special needs.

Aspergers Children “Block-Out” Their Emotions

Parenting children with Aspergers and HFA can be a daunting task. In layman’s terms, Aspergers is a developmental disability that affects the way children develop and understand the world around them, and is directly linked to their senses and sensory processing. This means they often use certain behaviors to block out their emotions or response to pain.

Older Teens and Young Adult Children With Aspergers Still Living At Home

Your older teenager or young “adult child” isn’t sure what to do, and he is asking you for money every few days. How do you cut the purse strings and teach him to be independent? Parents of teens with Aspergers face many problems that other parents do not. Time is running out for teaching their adolescent how to become an independent adult. As one mother put it, "There's so little time, yet so much left to do."Click here to read the full article…

Living with an Aspergers Spouse/Partner

Research reveals that the divorce rate for people with Aspergers is around 80%. Why so high!? The answer may be found in how the symptoms of Aspergers affect intimate relationships. People with Aspergers often find it difficult to understand others and express themselves. They may seem to lose interest in people over time, appear aloof, and are often mistaken as self-centered, vain individuals.

Online Parent Coaching for Parents of Asperger's Children

If you’re the parent of a child with Aspergers or High-Functioning Autism, you know it can be a struggle from time to time. Your child may be experiencing: obsessive routines; problems coping in social situations; intense tantrums and meltdowns; over-sensitivity to sounds, tastes, smells and sights; preoccupation with one subject of interest; and being overwhelmed by even the smallest of changes.

Unraveling The Mystery Behind Asperger's and High-Functioning Autism

Parents, teachers, and the general public have a lot of misconceptions of Asperger's and High-Functioning Autism. Many myths abound, and the lack of knowledge is both disturbing and harmful to kids and teens who struggle with the disorder.

Parenting Children and Teens with High-Functioning Autism

Two traits often found in kids with High-Functioning Autism are “mind-blindness” (i.e., the inability to predict the beliefs and intentions of others) and “alexithymia” (i.e., the inability to identify and interpret emotional signals in others). These two traits reduce the youngster’s ability to empathize with peers. As a result, he or she may be perceived by adults and other children as selfish, insensitive and uncaring.Click here to read the full article...

Highly Effective Research-Based Parenting Strategies for Children with Asperger's and HFA

Become an expert in helping your child cope with his or her “out-of-control” emotions, inability to make and keep friends, stress, anger, thinking errors, and resistance to change.